Two children, both younger than 3 years old, are ill in France after eating raw milk cheese contaminated with _Escherichia coli_ O26, according to authorities. The children have developed hemolytic uremic syndrome (HUS), a type of kidney failure that can be fatal, particularly in young children. The French Ministry of Agriculture and Food said the infections were "severe" but did not mention the children's current state of health.

The children live in the same part of France. Both ate raw milk reblochon -- a type of cheese -- produced by the company Fromagere d'Eteaux, which is part of the Lactalis group. (A 2017 salmonella outbreak was traced to the Lactalis company's infant formula. The outbreak sickened 38 babies in France, 2 in Spain and one in Greece in 2017. The formula, which was ultimately recalled, had been distributed to more than 80 countries.)

Reblochon packaged under the brands Pochat and Beulet, with health mark FR 74 116 050 CE and made on the Eteaux site of the company in the Haute-Savoie region of the country, has been withdrawn from the market. The Pochat et fils 450-gram cheese has lot number 185394214 and date of 24 Dec 2018. The Beulet brand is also 450 grams but has lot number 185394230 and date of 10 Dec 2018.

Investigations are ongoing by the company and at the dairy farms to determine the source of _E. coli_ O26 contamination. Analysis by the producer on the implicated batch at the beginning of the manufacturing process did not reveal contamination with _E. coli_ O26. However, retrospective analyses on a sample of cheese kept by them did reveal contamination with the pathogen.

French authorities have urged people who bought the cheeses not to consume them -- especially young children, pregnant women, immunocompromised people and the elderly -- and to return them to where they were purchased. The French Ministry of Agriculture and Food advise that, as a precaution, raw milk cheeses should never be eaten by young children, and types such as Emmental and Comte processed and pasteurized cheese should be preferred.

Santé Publique France and the National Reference Center for _E. coli_ are continuing enhanced surveillance of HUS that may occur after consumption of products contaminated with _E. coli_ O26 to detect potential new cases related to this outbreak. Symptoms include abdominal cramps and diarrhea that may progress to bloody diarrhea. The incubation period can range from 3 to 8 days, and most patients recover within 10 days.

Santé Publique France, the national public health agency, is also still investigating an outbreak of salmonella linked to raw milk cheese that has 83 possible cases. In all, 15 people were hospitalized for salmonellosis, but no deaths were reported. The French Ministry of Agriculture and Food said the outbreak had been traced to reblochon made by Fromagerie de la Tournette. The company recalled certain cheeses last month [November 2018]. Products were also distributed to Austria, Belgium, Germany and Italy. The outbreak link was made from consumption history of patients and not from positive sampling of the cheese. A total of 65 patients have been interviewed about symptoms and food consumption history. Of these, 80% reported eating reblochon made with raw milk before onset of illness.

[byline: Joe Whitworth]

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communicated by: ProMED-mail <promed@promedmail.org>

[The last posting in June 2018 (E. coli EHEC - France: O26, unpasteurized cheese, alert, recallhttp://promedmail.org/post/20180511.5792857) mentioned 14 cases of E. coli EHEC O26 infection; the above report refers to two further cases with HUS. The outbreak of salmonellosis, though linked to a similar type of cheese made with raw milk, is quite separate <https://www.foodsafetynews.com/2018/12/sharp-rise-in-french-salmonella-outbreak-linked-to-raw-milk-cheese/>.

Unpasteurized dairy products remain a potential risk for a variety of pathogens, including enterohemorrhagic _E. coli_ (EHEC), either the prototypic serotype or one of the other serotypes; in this case, O26. In analyzing the genetic and phenotypic profiles of non-O157 groups of EHEC, it has been found that they belong to their own lineages and have unique profiles of virulence traits different from the prototypic O157 strain (1). The serogroups appearing to be most prominent are O26, O111, O128, and O103 (2), the O26 serotype being the implicated strain in this outbreak.

From the past reports and this follow-up, many of the cases had HUS (6 out of 14 in the June 2018 posting, plus 2 mentioned above, suggesting 8 out of 16). For so many of the reported cases to be associated with HUS is very unusual; I would suspect that more cases are known or the particular strain is a hyperproducer of Shiga toxin or the specific toxin is more potent.

"Risk factors for the subsequent development of HUS after EHEC include children less than 10 years of age, elevated white blood cell counts, persistent low platelet counts without reversal and the use of either antimicrobial agents or antimotility agents during the diarrhea stage before or after bloody diarrhea develops. Since fever is generally not part of the presentation but significant abdominal pain is, patients with diarrhea, significant abdominal pain and no fever should be considered to have EHEC infection, and antimicrobial or antimotility agents should be avoided. Additionally, certain strains -- for example, the so-called clade 8 and the chimeric organism _E. coli_ O104:H4 -- can be associated with a higher risk of HUS.

"HUS itself is a thrombotic illness primarily caused by the effects of the EHEC-produced Shiga toxin acting on the vascular endometrium of organs where the toxin's receptors are expressed, particularly the kidney and brain. The syndrome consists of the combination of prominent low platelet counts (thrombocytopenia), intravascular red blood cell destruction (hemolysis), and diminished kidney function that can require hemodialysis. Neurological involvement occurs mostly in those who develop renal failure and the central nervous system involvement portends much higher mortality. Indeed, most of the acute mortality relates to neurological disease. Most patients will recover, but some, perhaps 10%, remain with renal failure and require chronic hemodialysis."